Provider Demographics
NPI:1568462620
Name:ANDERSON, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 MOUNT AUBURN ST
Mailing Address - Street 2:STE 517
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-5600
Mailing Address - Country:US
Mailing Address - Phone:617-868-0847
Mailing Address - Fax:617-491-6048
Practice Address - Street 1:300 MOUNT AUBURN ST
Practice Address - Street 2:STE 517
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5600
Practice Address - Country:US
Practice Address - Phone:617-868-0847
Practice Address - Fax:617-491-6048
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76521207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3099547Medicaid
MAJ12973Medicare ID - Type Unspecified
MAE61175Medicare UPIN